Total Pancreatectomy

• Total pancreatectomy for pancreatic cancer is usually not recommended as the endocrine and exocrine functions of the pancreas are totally lost which result in severe metabolic disturbances.
• Total pancreatectomy may prevent pancreatic fistulas and provide a radical eradication of the tumor.
• The median survival rates are reported to be shorter after total pancreatectomy than after pancreaticoduodenectomy.
• Total pancreatectomy is considered in a few selected patients, e.g. patients with positive resection margins in frozen sections (e.g. IPMN) or tumors not resectable with partial pancreactectomy.
• If total pancreatectomy is opted, retaining the pylorus improves the post surgical outcome.

Distal or caudal pancreatectomy

• When the tumor is located in the left side of the pancreas, a distal or caudal pancreatectomy is considered. Often the tumors that arise in the left region of the pancreas are diagnosed at a very late stage when metastasis has already occurred.
• Resection is a possibility only if the tumor is localised and the celiac axis, the superior mesenteric arteries are not involved. Involvement of splenic vessels is not a contraindication for resection.
• The entire pancreatic body and tail has to be assessed along with the assessment of celiac axis, periaortic region and the peritoneum.
• The spleen is resected in most of the cases after ligating the splenic artery: removal of the spleen assists dissection of the tail. In small and more indolent tumors, spleen resection is a well described procedure with documented benefits.
• The left sided tumors are typically larger in size and lymph nodes are involved to a lesser extent as compared to the right sided tumors.

Pancreaticoduodenectomy

Pancreaticoduodenectomy is performed in patients with tumors in the head, neck, or uncinate process of the pancreas. Recent advances in the surgical techniques and post operative care have improved the outcomes and even long term survival rates. The procedure of pancreaticoduodenectomy is further classified as:

• Kausch-Whipple pancreaticoduodenectomy (Classical Whipple procedure)
• Pylorus preserving pancreaticoduodenectomy (PPPD)

Assessment for resectibility

• The first step in the surgical resection is to rule out distant spread of the disease. The surgeon has to explore for spread of the tumor in the liver, peritoneum, and distant lymph nodes. 

• If the tumor shows involvement in the superior mesenteric artery (SMA), celiac trunk, or hepatic arteries resection is usually not considered while it can be carried out if the superior mesenteric vein (SMV) or the portal vein (PV) is affected. 

• Surgery is considered only if the intraoperative assessment confirms that the tumor is localised in the head, neck and uncinate process of the pancreas. 

• Surgery is considered only if the intraoperative assessment confirms that the tumor is localised in the head, neck and uncinate process of the pancreas. 

• In PPPD, the pylorus is preserved and the duodenum is divided after the pyloric ring. 

• The advantages of PPPD are shorter operative time, minimal effect on the function of pylorus and stomach as a reservoir of food and on the digestive functions of the stomach. 

• Studies have reported that the adverse effects, hospitalisation period, survival time and safety in both the types of resection surgeries are comparable.⁶ PPPD is now a preferred choice for patients with pancreatic adenocarcinoma although level I evidence is lacking.

Remnant pancreas reconstruction

The remnant pancreas is anastomosed either to the jejunum or the stomach to prevent leakage of the pancreatic juices. The anastomotic techniques are:

• Pancreaticojejunostomy
• The duct to mucosa technique is commonly used in pancreaticojejunostomy; a number of variations are described with excellent results.
• Pancreaticogastrostomy
• The procedure involves lodging the pancreatic remnant or the pancreatic duct into the stomach or pancreatic duct into the gastric mucosa.
• The alkaline juices from pancreas may alter gastric pH and affect the gastric mucosa but studies reveal comparable results in terms of survival, complications and recovery with both pancreaticojejunostomy and pancreaticogastrostomy.
• Pancreaticoenteric anastomosis is crucial as it is the single major cause of morbidity and mortality after surgery. The choice of the technique is usually at the surgeon's discretion as it requires expertise and precise implementation.

Reconstruction for biliodigestive continuity

• Gastrojejunostomy is performed after Kausch- Whipple procedure, while a duodenojejunostomy is performed after PPPD.
• Studies have indicated that antrectomy does not have an advantage over PPPD in terms of delayed gastric emptying (DGE). Post surgical complications and extended radical surgery have been found to increase DGE.⁷
• An antecolic duodenojejinostomy is reported to reduce the incidence of post operative DGE.

Types of Liver Transplantation

There are two options for liver transplantation:

• Cadaver donor transplantation
• Living donor transplantation.

C adaveric liver transplantation :

Here the liver of a brain dead person is used for transplantation whose family volunteers to donate his / her liver for transplantation.

Living related liver transplantation :

This has been a further step to answer the shortage of organs for children. In living related liver transplantation, a part of the liver from a living related donor is used in the child. In India , the human organ donation act was passed in 1984. The donor has to be spouse or first degree relative or emotionally related to the patient. In India , presently cadaveric donation has not gained momentum and majority of transplants, whether renal or liver are living related.hioption f liver transplant:

Auxiliary liver transplant :

Auxiliary liver transplant is used in occasional patients. In auxiliary liver transplant a part of the donor liver (usually segments 2+3) is implanted beside or in continuity with the native liver( patients own liver). The main purpose of this form of liver transplant is to ensure that the native liver is retained in the event of graft failure or for the future development of gene therapy. Auxiliary transplant is now accepted therapy for Criggler-Najjar syndrome type I and also for propionicacidemia and ornithine transcarbamalase deficiency. Its role in fulminant hepatic failure is more controversial.

Rex Shunt

For portal hypertension there are different surgical options.

Two basic surgical choices include palliative shunts, which essentially decrease the severity of symptoms, and restorative shunts, which restore normal blood flow through the liver.

About rex shunt?

Use of the restorative shunt, the meso-rex bypass — or "rex shunt" for short.
Because the rex shunt restores normal blood flow to an otherwise normal liver, it is believe that this is the treatment of choice for children with extra-hepatic portal vein thrombosis (EHPVT).

The shunt bypasses the blocked portal vein and restores venous blood flow to the liver. A vein (usually the jugular vein in the neck) is used to build a bridge around the blockage. Blood flows from the large intestinal veins, across the bridge, around the blockage and back into the liver. Blood can then flow from the intestines into the liver in the "normal" way.

Following the surgery, the symptoms of portal hypertension usually resolve very quickly. It is also believe that restoration of normal portal blood flow to the liver allows the liver to recover some of the functions that may have been impaired because of the obstruction thereby allowing the child to grow and develop to their full potential.

Arteriovenous (AV) fistula: What is it?

A-V fistula

A fistula is an abnormal connection between two parts of the body. An arteriovenous (AV) fistula refers to an abnormal connection between an artery and a vein.

An arteriovenous (AV) fistula is an abnormal passageway between an artery and a vein. Although it most often occurs in the legs or arms, an AV fistula can occur anywhere in the body, including the brain. An AV fistula may also be created surgically to provide access for hemodialysis in people with end-stage kidney failure.

Normally, your blood flows from arteries through capillaries and back to your heart in veins. When an AV fistula is present, blood flows directly from an artery into a vein, bypassing the capillaries. If the volume of diverted blood flow is large, tissues downstream receive less blood supply. In addition, heart failure may occur due to the increased volume of blood returned to the heart.

A doctor may suspect an AV fistula by an abnormal sound (bruit) heard over the artery with a stethoscope. The sound is due to turbulent blood flow between the artery and the vein. Small fistulas following injury sometimes close without treatment. But larger fistulas usually require treatment, which may include:

• Endovascular coils inserted into the fistula to close it
• Surgery to block the abnormal channel

Advanced Hepatobiliary Surgery

Procedures & Indications

Hepatobiliary and Pancreas

We, at the Center for Liver Diseases & Transplantation are committed to bringing new and advanced diagnostic tools, medical treatments and surgical options to the physicians and patients we serve. Through this procedure profile, our physicians illustrate surgical techniques and capabilities that provide you with a window into their practice of diagnosis, treatment and patient follow-up.

Surgical Capabilities | Biliary Tumors and Injuries | Diseases of the Pancreas - Surgical Options | Liver Cancer - Surgical Options | Why Choose Us? | For More Information | .
Surgical Capabilities

New diagnostic and surgical capabilities have enabled the Liver Center’s hepatobiliary team to better treat hepatobiliary and pancreatic carcinoma as well as other diseases affecting these organs. Our skilled hepatobiliary team -- comprised of surgeons, interventional endoscopists, radiologists and hepatologists -- works together to provide surgical treatment for the following problems:

Biliary
* Carcinoma of the gallbladder
* Malignant tumors of the bile duct
* Bile duct injuries and strictures
* Choledochal cysts
* Recurrent pyogenic cholangitis
Pancreas
* Pancreatitis
* Pancreatic pseudocyst
* Malignant neoplasms of the pancreas
* Cystic neoplasms of the pancreas
* Pancreatic islet cell tumors
Liver
* Hepatic trauma
* Metastatic neoplasms of the liver (Cancer originated elsewhere & spread to liver)
* Benign (Non cancerous) tumors and cysts of the liver
* Portal hypertension (portasystemic shunts)

With the use of laparoscopy and endoscopic ultrasound (EUS), all patients with malignancies are staged pre-operatively. Following staging, our hepatobiliary team works in conjunction with the referring physician to determine the treatment best suited for the patient's condition. Because choosing a treatment plan is an important decision, we review all options with patients and family members as well as their referring physician, explaining the benefits and disadvantages of each option.

Biliary Tumors and Injuries

Biliary surgery is most frequently performed for stones, strictures and tumors. Among the treatment options available at the Liver Center, Apollo include:

Resection of primary biliary neoplasms (cholangiocarcinoma
Treatment of bile duct cancer usually requires removal of the bile duct and possibly portions of the liver, gallbladder, pancreas and small intestine. After resecting the neoplasms -- either through open surgery or laparoscopically -- the surgeon reconnects the bile ducts to the small intestine for proper biliary drainage (see illustration).

Biliary Drainage Procedures

Biliary drainage procedures are performed when the bile duct becomes blocked, narrowed or injured. During surgery, continuity of the biliary tree is usually re-established via a hepaticojejunostomy.

Diseases of the Pancreas - Surgical Options
Upon referral of a suspected pancreatic pathology, the Liver Center’s hepatobiliary team initiates a pre-operative work up which usually includes an evaluation of the pancreas via EUS. This evaluation helps to determine the location of the pathology in the head, neck, body or tail of the pancreas.

Subsequent treatment options include:

Pancreaticoduodenectomy (Whipple Procedure)
A pancreaticoduodenectomy, also known as a Whipple procedure, involves the removal of the pancreas head due to a tumor in the pancreas or bile duct, or pancreatitis.

If a tumor exists in the head of the pancreas, it is usually necessary to remove the pancreas head, duodenum, gallbladder and a portion of the bile duct Figure 1). Sometimes, part of the stomach is also removed.

The end of a patient's bile duct and the remaining pancreas are then connected to the small bowel (Figure 2) to ensure flow of bile and enzymes into the intestines.

Distal Pancreatectomy (laparoscopic or open)
Indicated for tumors in the body and tail of the pancreas, a distal pancreatectomy involves the removal of cystic neoplasms either laparoscopically or with open surgery. With both laparoscopic and open distal pancreatectomy procedures, surgeons attempt to preserve the spleen.

Drainage Procedures

With chronic pancreatitis, a dilated pancreatic duct usually reflects obstruction. Procedures to improve ductal drainage include:

-Longitudinal Pancreaticojejunostomy (Puestow Procedure): The pancreatic duct is opened from the tail to the head of the pancreas and attached to the small bowel.
-Distal Pancreaticojejunostomy (Du Val Procedure): The pancreas is divided transversely at the neck, and the body and tail are drained via attachment to the small bowel.
-Sphincteroplasty: When endoscopic sphincterotomy is unsuccessful, surgical sphincteroplasty may be required of the minor or major papilla.

Pancreas Transplantation: A pancreas transplant is indicated for patients with insulin-dependent (Type 1) diabetes.

Liver Cancer - Surgical Options
When determining treatment options for tumors of the liver, the hepatobiliary team reviews the results of one's pre-operative evaluation and overall health to recommend appropriate treatment options. The majority of liver metastases come from the colon. The single tumor or more than one tumor confined to either left or right side of the liver can be successfully resected with 5-year survival as high as 60%.

Treatments for tumors of the liver include:

Surgical Resection (Tumor Removal) -- Open or Laparoscopic
Typically, surgeons can safely remove up to 70% of the liver (if there is no fibrosis) and expect full regeneration. During resection, the surgeon first uses ultrasound to determine the tumor(s) proximity to hepatic structures and then removes it with as little liver as possible, while ensuring a margin free of tumor.

For patients who may not have enough liver reserve, portal vein embolization is used pre-operatively.

This technique, which involves the insertion of tiny microspheres into the portal vein, blocks blood flow to the portion of the liver containing tumor(s), and results in the enlargement of the remaining liver segments on which the patient will depend after resection.

If the location of a benign tumor is superficial and small in size, the operation can be performed laparoscopically (by making small punctures in the abdomen while viewing through a video camera). We are one of the very few centers in South East Asia offering Laparoscopic Liver Resection.

The Center for Liver Diseases and Transplantation, Apollo is equipped with the state of the art technology related to liver surgery and using the laparoscopic ‘Argon Beam Laser’ as well as as ‘Tissue Link™’ in combination with other methods of liver resection like ‘CUSA™’ and ‘laparoscopic vascular stapling’, we ensure a very high rate of bloodless liver surgery at Apollo.

Liver Transplantation

While a liver transplant represents the best cure for most patients with non-metastic liver cancer, the limited organ supply may make this option unattainable. The eligibility criteria for transplantation is the presence of a single HCC tumor 5 cm. or less in diameter, or three or fewer tumor modules, each 3 cm. or less in diameter. Both living-related and cadaveric liver transplants are options for patients at the Center for Liver Diseases & Transplantation, Apollo.

Ablation (Radiofrequency or Cryoablation)
Patients who are not candidates for resection or transplantation due to inadequate liver reserve, large or multiple lesions in multiple lobes, fibrosis or cirrhosis can benefit from treatments such as CT-guided, laparoscopic or open radiofrequency or cryoablation.

With new radiofrequency (RF) ablation technology, liver tumors up to 7 cm. in diameter can be treated. The ideal patient for RFA generally has no more than three lesions that are no greater than 5 cm. (about 1.5 inch) in size.

RF ablation delivers radiofrequency energy to the tumor, heating it to temperatures above 113 degrees Fahrenheit and thereby destroying the lesion. During cryoablation, argon gas is delivered through probes inserted into the liver, creating an ice ball that freezes the tumor and destroys its cells (see illustration).

Percutaneous Ethanol Injection Therapy (PEIT)
Another option for patients who are not surgical candidates, PEIT involves the injection of alcohol into the tumor, causing immediate dehydration of the cytoplasm with consequent coagulation, necrosis and fibrous reaction. PEIT results in complete ablation in up to 75% of selected patients with hepatocellular carcinoma.

Hepatic Arterial Pumps
Indicated for patients with metastatic colon cancer, hepatic arterial pumps deliver chemotherapy to the liver through a catheter placed in the hepatic artery. The catheter is typically inserted via laparoscopic or open surgery and a pump, which delivers the chemotherapy, is implanted subcutaneously. The pump is generally filled with chemotherapy once a month.

Why Choose Us?
Apollo Center for Liver Disease & Transplantation offers comprehensive specialty care for diseases of the liver, pancreas and bile duct. We emphasize ongoing communication with referring physicians and incorporate them in the decision process of their patient's medical management. Following treatment, we follow up our care with an organized discharge report to the referring physician.

For patients requiring hospitalization, we have a dedicated hepatobiliary critical care unit, a heptobiliary physician on-call, anesthesia staff and a specialized O.R. nursing team. At the Liver Center, our focus is on providing experienced, personalized care for all our patients.

With the use of advanced technology and surgical methods, patients now have more options than ever for the treatment of hepatobiliary disease. Our physicians are trained at the world’s most renowned centers in Hepatobiliary surgery and Liver Transplantation and are actively involved in clinical research and offer multiple studies in areas such as hepatocellular carcinoma, gastroenterology and viral hepatitis. Additionally, our hepatobiliary team offers outreach ‘Liver Clinics’ in the various units of Apollo hospital, providing pre- and post-operative hepatobiliary care close to home in & around Delhi.

We welcome your inquiries regarding treatment options, outreach locations or referrals.

For further information on surgical options for advanced hepatobiliary and pancreatic diseases, please contact

Dr Subash Gupta
Liver Transplant Surgeon
Indraprastha Apollo Hospital
Sarita Vihar Delhi
Email: anscreativity@gmail.com

Other Liver Related Surgeries

• LIVER SURGERY
• RF ABLATION
• PORTAL HYPERTENSION SURGERY
• GALL BLADDER SURGERY
• ADVANCED HEPATOBILIARY SURGERY
• PANCREATIC SURGERY
• ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
  

LIVER SURGERY
Liver surgery comprises various operations of the liver for different disorders. The most common operation performed on the liver is a resection (removal of a portion of the liver). The most typical indication for liver resection is a malignant tumor. Tumors can be primary (developed in the liver) or metastatic (developed in another organ, then migrated to the liver).

In liver surgery, tumor resection is often the only curative treatment for patients suffering from liver cancer. A liver resection takes approximately 3-5 hours and can be performed without the need for blood transfusion (see bloodless surgery). Up to 75% of the liver tissue can be safely removed. The hospital stay is about 5 days and complete recovery occurs in 5-6 weeks. The resected liver regenerates to its preoperative size in 6-8 weeks. Excellent results from liver resections are usually achieved.

Hepatobiliary Surgery

The following is a list of the most common hepatobiliary conditions and procedures.
Common Conditions
Primary Liver Tumor

• Hepatocellular carcinoma
• Hepatoblastoma
• Cystadenocarcinoma

Metastatic Liver Tumors

• Colorectal cancer
  
• Pancreatic cancer
• Carcinoid tumor
• Neuroendocrine tumor
• Adrenal carcinoma
• Soft tissue tumors/sarcoma
• Gastric cancer
• Breast cancer
• Melanoma
• Ovarian cancer

Benign Liver Tumors

• Adenoma
• Cavernous hemangioma
• Focal nodular hyperplasia

Liver Cyst / Abscess

• Polycystic liver disease
• Congenital cyst
• Liver abscess
• Hydatid cyst

Gall Bladder Tumors

• Gall bladder cancer
• Gall bladder polyp
• Porcelain gall bladder
• Cholangiocarcinoma
• Klatskin Tumor
• Choledochal Cyst
• Post-Cholecystectomy Stricture

Common Procedures
Minimally Invasive Liver Procedures

• Diagnostic laparoscopy and biopsy
• Radiofrequency ablation (RFA)
• Percutaneous ethanol injection
• Hepatic artery infusion pump
• Hepatic artery chemoembolization

Conventional Liver Procedures

• Hepatectomy
  
• Marsupialization or unroofing of liver cysts
• Drainage of liver abscess

Gallbladder and Biliary Procedures

• Radical cholecystectomy
• Resection of Klatskin tumors and cholangiocarcinoma
• Bile duct reconstruction
• Common bile duct exploration

Surgery for Portal Hypertension

R F ABLATION
Radiofrequency ablation, sometimes referred to as RFA, is a minimally invasive treatment for cancer. It is an image-guided technique that heats and destroys cancer cells. Radiofrequency ablation is used to treat two types of liver cancers 1) Hepatocellular carcinoma, which is a primary liver cancer (meaning it begins in the liver) and 2) Colon cancer that metastasizes or spreads from the colon to the liver.

A special needle electrode is placed in the tumour under the guidance of an imaging method such as ultrasound, computed tomography (CT) scanning, or magnetic resonance (MR) imaging. A radiofrequency current then is passed through the electrode to heat the tumour tissue near the needle tip and ablate—or eliminate—it. The heat from radiofrequency energy also closes up small blood vessels, thereby minimizing the risk of bleeding. In general, radiofrequency ablation causes only minimal discomfort and may be done as an outpatient procedure without general anaesthesia.

PORTAL HYPERTENSION SURGERY
Portal hypertension is increased blood pressure in the veins of abdominal organs. The primary vein that carries blood from the abdominal organs to the liver is called the portal vein. When this vein clots or when the liver develops scar tissue from disease and compresses the vein, the blood pressure in the vein goes up and portal hypertension develops. Portal hypertension surgery is indicated in patients who have severe hemorrhaging, or internal bleeding, due to varices that cannot be controlled.

The surgical procedure that is most commonly used is called distal splenorenal shunt (DSRS). The DSRS is a surgical procedure during which the vein from the spleen (called the splenic vein) is detached from the portal vein and attached to the left kidney (renal) vein. This surgery selectively reduces the pressure in the varices and controls the bleeding. In DSRS, a patient receives general anesthesia. A surgeon makes an incision in the abdomen to access the blood vessels around the liver and joins the splenic and left renal vein. This action reduces blood pressure in any esophageal varices.The procedure has a 90 percent success rates at preventing bleeding from recurring.

GALL BLADDER SURGERY
Gallbladder surgery – also known as cholecystectomy – is used to treat gallstones, cancer and other disorders that affect the gallbladder. The gallbladder is the organ that stores excess bile not immediately needed for digestion.

This surgery can be performed as either laparoscopy or traditional open surgery. A gallbladder operation is usually done using "keyhole" surgery - also known as laparoscopic cholecystectomy. This means your surgeon can remove the organ without having to make a large cut on your abdomen. During laparoscopy, several small incisions are made in the abdomen and a thin, tube-like instrument called a laparoscope is inserted into the body. A camera and light attached to the laparoscope provide images of the gallbladder that are transmitted to a monitor, allowing the surgeon to view the abdominal cavity while removing the gallbladder. This technique is used in the vast majority of gallbladder surgeries because it is less invasive and reduces scarring and the potential for post-surgical pain and complications.

ADVANCED HEPATOBILIARY SURGERY
Hepatobiliary surgery consists of highly technical challenging procedures that deal with all pathological conditions that affect the liver, gallbladder, bile ducts, pancreas, and duodenum. These conditions can be the result of congenital abnormalities, inflammation, infection, benign or malignant tumors, or the result of traumatic injuries. Hepatobiliary Surgery is a natural extension of liver transplantation.

PANCREATIC SURGERY
Pancreatic surgery encompasses a wide variety of surgical procedures concerning the pancreas (a gland located behind the stomach just below the liver). Disorders of pancreas can be divided onto those caused by tumors (benign or malignant) and those caused by inflammation (acute or chronic). Distal Pancreatectomy involves removal of the tail of the pancreas, or the tail plus a portion of the body. The spleen is sometimes removed as well. Total Pancreatectomy

Operations on the pancreas typically require an abdominal incision with some dissection of the stomach and intestines to expose the pancreas located deep within the abdomen. Many of these endocrine tumors may be dissected out of the substance of the pancreas, but in some cases may require partial removal of the pancreas (pancreatectomy).
removes the entire pancreas, and is rarely used.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
ERCP stands for endoscopic retrograde cholangiopancreatography. It is a procedure that uses an endoscope to examine and x-ray the pancreatic duct, hepatic duct, common bile duct, duodenal papilla and gallbladder. An endoscope is passed through the mouth and down into the first part of the small intestine (duodenum). A smaller tube (catheter) is then inserted through the endoscope into the bile and pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. The purpose of the examination is to detect any diseases or irregularities in the bile or pancreatic ducts. The examination may be used to locate, and in some cases remove, gallstones stuck in the bile duct. It is also possible to reveal cancer, infections and cirrhosis of the liver.To investigate jaundice where the patient goes yellow as the result of a blockage to the bile ducts and to investigate otherwise unexplained abdominal pain.

Magnetic Resonance Cholangiopancreatography

Magnetic Resonance Cholangiopancreatography represents a relatively new development in MR technology that allows for rapid evaluation of the biliary tract, pancreatic duct and gallbladder without contrast material administration, instrumentation or radiation. To date, over 2000 MRCPs have been performed at the Medical College of Virginia Hospitals. Special imaging sequences that are heavily-T2-weighted are utilized to depict the biliary tract, pancreatic duct and gallbladder as high signal intensity or bright structures owing to the fluid within them. Studies performed at the Medical College of Virginia Hospitals as well as at other institutions have shown that the accuracy of MRCP is comparable to that known as ERCP (endoscopic retrograde cholangiopancreatography, the traditional but invasive means of imaging the pancreaticobiliary system) in the evaluation of choledocholithiasis, malignant obstruction, anatomic variants and chronic pancreatitis. In most instances, MRCP can be completed in 10 minutes and is easily performed as an outpatient examination. Since its introduction in 1991, the role of MRCP in evaluating pancreaticobiliary disease has continued to evolve. MRCP is assuming a larger role as a rapid, accurate and non-invasive alternative to diagnostic ERCP. During the past several years, radiologists and nonradiologists alike have shown a keen interest in MRCP and its clinical applications. Technical refinements such as fast MR sequences that allow for imaging of the entire biliary tract and pancreatic duct in a single breathhold have resulted in marked improvement in the quality and diagnostic yield of MRCPs. As the quality of MRCPs has improved, the clinical applications of this technique have expanded such that MRCP is now replacing diagnostic ERCP in many instances. Current techniques allow for depiction of obstructed or dilated bile and pancreatic ducts in essentially all patients. Normal caliber extrahepatic bile ducts and central intrahepatic ducts are routinely depicted in as many as 100% of patients. Although the normal caliber pancreatic duct may be more difficult to visualize than the bile duct, the normal pancreatic duct can be visualized in 80-95% of cases. Dilated ducts proximal to an obstruction are well visualized, usually better than with ERCP where there can be difficulty in opacifying ducts proximal to a high-grade obstruction. MRCP avoids the complications of ERCP such as pancreatitis (3-5%), sepsis, perforation and hemorrhage. The main disadvantage of MRCP is that it is purely diagnostic and does not provide access for therapeutic intervention.

Clinical Applications

Screening Examination In Patients With Low or Intermediate Probability Of Choledocholithiasis:

MRCP is useful as a noninvasive means of determining the presence or absence of common bile duct stones as well as their number, size and location. With the use of state-of-the-art MRCP techniques, MRCP has a sensitivity of 95-100% in the detection common bile duct stones. MRCP is particularly useful in the evaluation of patients with suspected gallstone pancreatitis and in patients with non-specific abdominal pain and normal liver-associated enzymes. In these settings, an MRCP that shows no evidence of a common bile duct may result in avoidance of an unnecessary diagnostic ERCP.

Failed or Incomplete ERCP:

MRCP provides a means of demonstrating the biliary tract and pancreatic duct after a failed or incomplete ERCP. Although ERCP is still regarded as the standard of reference for evaluating the bile duct and pancreatic duct, ERCP is technically challenging and is associated with a failed cannulation rate of 10-20%. Anatomic alterations such as Billroth II anatomy, periampullary diverticula, duodenal stenosis and periampullary masses may contribute to failed ERCP attempts. MRCP also allows for evaluation of ducts in patients who may not be candidates for ERCP due to cervical spinal fractures, head and neck tumors, sleep apnea, or other diseases or injuries that preclude placement of the endoscope or positioning the patient for ERCP.

Variant Ductal Anatomy:

MRCP is useful in demonstrating variant ductal anatomy and congenital anomalies of the biliary tract and pancreatic duct such as pancreas divisum, choledochal cyst, annular pancreas, abnormal pancreaticobiliary junctions and aberrant bile ducts. There may also be a role for MRCP in the evaluation of patients prior to laparoscopic cholecystectomy to identify and define variant biliary anatomy that might complicate the surgical procedure. MRCP may be useful in sorting out complex anatomic variants of the pancreaticobiliary tract.

Post-operative Anatomy:

In our experience, MRCP has been shown to be helpful in demonstrating the bile ducts in patients with surgically-altered biliary anatomy such as that associated with biliary-enteric anastomoses and liver transplantations. MRCP is particularly useful in the setting of surgical alterations of the gastrointestinal tract since the performance of ERCP may be difficult or impossible in this setting.

Primary Sclerosing Cholangitis (PSC):

MRCP provides a noninvasive means of diagnosing PSC and determining disease extent. In the detection of PSC, MRCP has been shown to have a sensitivity of 88%, a specificity of 97%, and positive and negative predictive values of 94%. MRCP depicts the mural irregularities, strictures and biliary calculi that characterize PSC. In contrast to ERCP, MRCP delineates the duct proximal to a complete obstruction and avoids the risk of ERCP-induced sepsis related to the injection of contrast material into an obstructed system.

Complications of Chronic Pancreatitis:

MRCP demonstrates ductal dilatation, strictures, intraductal calculi, fistulas and pseudocysts that occur as a result of chronic pancreatitis. One of the major roles of MRCP in this setting lies in defining the ductal anatomy and extent of ductal disease prior to surgical drainage procedures.

Pancreatic Surgery & Transplant

Pancreatic surgery encompasses a wide variety of surgical procedures concerning the pancreas (a gland located behind the stomach just below the liver). Disorders of pancreas can be divided onto those caused by tumors (benign or malignant) and those caused by inflammation (acute or chronic). The majority of surgical procedures performed on the

pancreas involve resection (removal) of the portion that is involved in the disease process. Prior to any operation on the pancreas the patient undergoes testing and is evaluated by multidisciplinary team of physicians. The management approaches to acute and chronic pancreatitis are different and may not necessarily involve surgical intervention. Often excellent results can be achieved through medical management. A major pancreatic resection takes approximately 4-6 hours and in most cases is performed without blood transfusion (see bloodless surgery). The post-operative hospital stay is about 7 days and complete recuperation time is expected in 6 weeks. In properly selected patients, excellent operative results and future quality of life are achieved.

Portal Hypertension Surgery.

The liver filters venous blood from abdominal organs. Portal hypertension is increased blood pressure in the veins of abdominal organs. The primary vein that carries blood from the abdominal organs to the liver is called the portal vein. When this vein clots or when the liver develops scar tissue from disease and compresses the vein, the blood pressure in the vein goes up and portal hypertension develops. Blood backing up in the veins of abdominal organs causes typical signs of portal hypertension such as ascites to develop. Ascites is free fluid in the abdomen caused by blood being under high pressure and some of its liquid portion squeezing through the vessels and settling in the abdomen.

Hypersplenism is an enlarged spleen caused by blood congestion and increased destruction of blood cells due to spleen hyperactivity. Gastrointestinal bleeding (bleeding into the stomach) results from rupture of varicose veins in the stomach and esophagus (swallowing tube). Varicose veins form a collateral venous network for the blood to escape into an area of lower pressure.

Portal hypertension can be accompanied by good liver function with good production of all necessary proteins. In such instances liver transplantation is not indicated (see liver transplantation). For long-term management an operation called portal vein shunting can be considered. During this operation the surgical connection between the portal vein or its branches and the vena cava (low-pressure vein caring blood from lower extremities and kidneys to the heart) or its branches is created. This allows blood from the portal vein to be redirected into the vena cava resolving the portal hypertension. This operation can be performed in selected patients with excellent long-term results.

Pancreatic Surgery

Pancreatic surgery encompasses a wide variety of surgical procedures concerning the pancreas (a gland located behind the stomach just below the liver). Disorders of pancreas can be divided onto those caused by tumors (benign or malignant) and those caused by inflammation (acute or chronic).

The majority of surgical procedures performed on the pancreas involve resection (removal) of the portion that is involved in the disease process. Prior to any operation on the pancreas the patient undergoes testing and is evaluated by multidisciplinary team of physicians. The management approaches to acute and chronic pancreatitis are different and may not necessarily involve surgical intervention. Often excellent results can be achieved through medical management.

A major pancreatic resection takes approximately 4-6 hours and in most cases is performed without blood transfusion (see bloodless surgery). The post-operative hospital stay is about 7 days and complete recuperation time is expected in 6 weeks. In properly selected patients, excellent operative results and future quality of life are achieved.